Learn About Anthem Blue Cross Prior Authorization

What Prior Authorization Is and How It Works

Prior authorization is a review process that health insurance companies use before paying for certain medical services, medications, or treatments. Anthem Blue Cross, one of the largest health insurance providers in the United States, requires prior authorization for many procedures and drugs to make sure the treatment is medically necessary before approving payment.

When your doctor wants to prescribe a medication or recommend a procedure, they may need to contact Anthem Blue Cross first to get approval. The insurance company reviews the request based on your medical history, the diagnosis, and clinical guidelines. This process typically takes a few business days, though urgent situations may be handled faster. During this time, your healthcare provider's office communicates directly with the insurance company—you don't usually need to do this yourself.

The main reason insurance companies use prior authorization is to control costs and prevent unnecessary medical spending. However, this process also serves as a safety check. It ensures that treatments align with current medical standards and that alternative, less expensive options haven't already been tried. For example, if your doctor wants to prescribe an expensive brand-name medication, Anthem Blue Cross might ask whether a generic version could work instead.

Different types of services trigger prior authorization requirements. Common examples include certain surgeries, advanced imaging tests like MRI or CT scans, specialty medications, mental health services, and physical therapy. Routine office visits, lab tests, and vaccinations typically don't require prior authorization.

Practical Takeaway: Before scheduling any procedure or starting a new medication, ask your doctor's office whether Anthem Blue Cross requires prior authorization. This simple question can prevent delays in your treatment and help you understand the timeline for approval.

Which Services Require Anthem Blue Cross Prior Authorization

Anthem Blue Cross maintains a list of services and medications that require prior authorization before treatment can begin. This list varies depending on your specific plan—individual plans, family plans, and employer-sponsored plans may have different requirements. Understanding which services need approval can help you plan your healthcare and avoid unexpected denials.

Surgical procedures are among the most common services requiring prior authorization. This includes both major surgeries like hip replacements or heart procedures and some outpatient surgeries. Orthopedic surgeries, bariatric surgeries, and joint replacement surgeries typically require approval. The insurance company reviews whether the surgery is medically necessary and whether non-surgical treatments have been attempted first.

Specialty medications often require prior authorization, especially newer drugs or expensive treatments. This includes biologic medications for conditions like rheumatoid arthritis, certain cancer treatments, and medications for chronic diseases. Anthem Blue Cross may request information about previous treatments you've tried before approving a new medication. Some medications require step therapy, meaning you must try a standard treatment first before the insurance company will cover a more expensive alternative.

Diagnostic and imaging services that require authorization include:

• MRI and CT scans in many situations
• Advanced cardiac imaging
• PET scans
• Certain ultrasound procedures
• Spinal imaging in some cases

Mental health services frequently require prior authorization, including inpatient psychiatric hospitalization, intensive outpatient programs, and extended therapy services. Physical therapy and rehabilitation services often need approval, especially if your plan limits the number of visits covered per year. Durable medical equipment like wheelchairs, oxygen supplies, or CPAP machines typically requires prior authorization to confirm medical necessity.

Home health services and skilled nursing facility care usually need approval before starting treatment. Certain infusion therapies and chemotherapy treatments require authorization. Some preventive services are covered without authorization, but if your doctor recommends additional screening beyond standard guidelines, prior authorization may be required.

Practical Takeaway: Review your Anthem Blue Cross plan documents or call the member services number to find out specifically which services your plan requires prior authorization for. Creating a personal list of these services helps you prepare when you need care.

How to Request Prior Authorization from Anthem Blue Cross

The prior authorization request process typically begins with your doctor's office, not with you directly. Your healthcare provider has established relationships with Anthem Blue Cross and knows how to submit requests properly. However, understanding the steps involved helps you follow up if needed and ensures nothing gets missed.

Your doctor's office gathers your medical information and submits a request to Anthem Blue Cross. This request includes your member ID number, the specific service or medication being requested, the medical reason for the treatment, your diagnosis, relevant test results, and any previous treatments you've tried. For medications, the doctor may need to explain why you haven't responded to less expensive alternatives or why those alternatives would be medically inappropriate.

Anthem Blue Cross has several ways to receive these requests. Many requests go through electronic systems that are faster than phone or fax. Your doctor's office may use a secure online portal designed for insurance submissions. Phone requests are also accepted, and some offices still use fax for certain types of requests. Electronic submissions typically result in faster turnaround times than other methods.

Once Anthem Blue Cross receives the request, a nurse reviewer or clinical pharmacist examines the information. They compare the treatment to clinical guidelines and your medical history. This review usually takes 2 to 3 business days for routine requests. Urgent requests may be reviewed within 24 hours if your doctor indicates the treatment is time-sensitive. For example, if you need surgery to address pain or functional problems, your doctor can request expedited review.

Anthem Blue Cross communicates the decision back to your doctor's office. The office then contacts you with the result. If approved, your doctor can proceed with treatment. If denied, Anthem Blue Cross provides an explanation of why the request didn't meet their criteria. Your doctor's office can then discuss alternative options with you or help you understand the reasons for denial.

Practical Takeaway: After your doctor's office submits a prior authorization request, follow up in 2 to 3 business days by calling the office to confirm it was received and approved. This prevents delays in scheduling your procedure or starting your medication.

What Happens If Prior Authorization Is Denied

A denial of prior authorization doesn't always mean you can't receive the treatment—it means Anthem Blue Cross determined it doesn't meet their coverage criteria based on the information provided. Understanding your options after a denial helps you work toward getting care you need.

When a request is denied, Anthem Blue Cross sends a detailed explanation to your doctor's office and often provides information about why the decision was made. Common reasons for denial include insufficient medical information, failure to try less expensive treatments first, the treatment not being medically necessary for your specific condition, or the treatment not being listed as covered under your plan. Some denials are based on the timing of treatment—for example, if you recently tried a treatment that needs more time to work before moving to the next option.

One option after denial is to have your doctor's office submit additional medical information. If the initial request lacked certain test results or documentation of previous treatments, adding this information may result in approval. Your doctor may write a letter explaining why the treatment is necessary for your specific situation, especially if your case is unusual or complicated.

You can request an internal appeal of the denial. This asks Anthem Blue Cross to reconsider the decision with fresh eyes. An appeal is typically reviewed by a different person or team than the original review. You usually have 60 days from the denial notice to request an appeal. Your doctor's office can help with this process by providing additional supporting documentation or a detailed clinical explanation.

If the appeal is also denied, you may have the option of requesting an external review. This means an independent medical professional outside of Anthem Blue Cross reviews the case. This step may be required before you can pursue legal action or complaints with your state's insurance department. The external review process has specific timelines and requirements that vary by state.

Another option is to work with your doctor to explore alternative treatments that Anthem Blue Cross does cover. Sometimes an alternative medication or procedure can achieve similar results. Your doctor can also discuss whether paying out-of-pocket for the denied treatment makes sense in your situation.

Practical Takeaway: If your prior authorization is denied, ask your doctor's office why it was denied and whether submitting additional information might change the decision. Most denials can be addressed by providing clearer documentation of medical necessity.

Managing Prior Authorization Timelines and Avoiding Delays

Prior authorization timelines matter,